Canada's Health Charter: Its Implications

MR. STAPELLS:

How many of you know the terms of the Physician's Oath? Hippocrates, who I remind you lived in the fourth century before Christ, formulated this lofty ethic which is, in part, as follows:

"I will use treatment to help the sick according to my ability and judgment, but never with a view to injury and wrong doing. I will keep pure and holy both my life and my art .... And whatsoever I shall see or hear in the course of my profession in my intercourse with men, if it be what should not be published abroad, I will never divulge, holding such things to be holy secrets."

This oath and its deep meaning is the problem doctors face when a plan for public health is debated.

And again, Hippocrates, philosophizing on the role of the doctor, said,

"For where there is love of man, there is also love of art. For some patients, though conscious that their condition is perilous, recover their health simply through their contentment with the goodness of the physician."

Can the personal, intimate relationship between a doctor and his patient and the voluntary doing of good beyond financial reward be maintained for the good of society under a National Provincial Health Plan. On the other hand, can this country countenance the economic and social loss arising out of illness which the co-ordination of finances and planning might avoid. That is the problem before us today.

But in June of 1961, when Mr. Justice Hall was appointed chairman of the Royal Commission on Health Services, the true shape and dimension of Canada's health problem was far from clear. Lawyers are notorious for attempting to solve problems of which they may have little knowledge. It cannot be said, however, that a man who has been a leader of the Saskatchewan Bar, Chief Justice of that province and now one of Her Majesty's Justices of the Supreme Court of Canada is lacking in a broad human knowledge. Further he has been closely associated with education as a member of the Senate of the University of Saskatchewan for many years as well as with the secondary education field as a trustee and in good time as President of the Catholic School Trustees of Saskatchewan. To complete his qualification, Mr. Justice Hall laboured with the problems of hospitals when he participated in the reorganization of St. Paul's Hospital Advisory Board.

The report of his Commission has now been published and for a look at Canada's Health Charter and its implications, it is my pleasure to introduce to you The Honourable Emmett M. Hall, D.C.L., Justice of the Supreme Court of Canada.

MR. JUSTICE HALL:

I am here because it was my privilege to have been Chairman of the Royal Commission on Health Services and to have worked with a small band of dedicated colleagues assisted by able consultants and by research scholars of the highest quality. Together we proposed that "as a nation we now take the necessary legislative, organizational and financial decisions to make all the fruits of the health sciences available to all our residents without hindrance of any kind", and to achieve this goal we formulated a "Health Charter for Canadians".

I am not here as an advocate to defend the recommendations of the Commission. That is for others who may be disposed to do so. The Commission spelled out as best it could the philosophical bases of its approach to the task assigned to it and the facts and figures upon which it made its proposal for a national-provincial programme. What is written is written and I can neither add nor take away from what we said-nor have I, in the months that have elapsed since the report was published, felt any inclination to do so.

The recommendations must stand or fall on their merits judged objectively in the light of present-day needs and possibilities and divorced from all selfish or sectional considerations, whether economic or political in their nature. Nor is it my purpose or function to enter into any discussion of medical economics though I must say that I regard Medicare, important as it is, as but a segment of the whole health services complex and I think I may be permitted to express the hope that governments may not be led into regarding this segment as dominating the whole field or as exhausting their functions and responsibilities in the health services field, for that would be an error fatal to a proper understanding of what one might call the grand design for Canada.

It is said and accepted that our citizens are Canada's greatest asset. The intense concern about education and the magnitude of the expenditures being projected in the field of education at all levels, are a realistic recognition of that fact.

But education by itself will not give Canada the citizens it must have to achieve the goals this country is capable of attaining, not only for its own citizens, but for humanity at large. The citizen must not only be educated, he must be healthy physically and mentally, otherwise much of the vast sums spent on education will not bring the rewards in human well-being and national prosperity which their expenditure are aimed to achieve. This co-partnership between education and health services was expressed in our report as follows:

The right to education is one now universally recognized in Canada. It is an entrenched right which no one would dare to challenge. It is now beyond question that all our young people must be better educated and more competently trained if Canada is to survive in this highly competitive age of specialization and automation. It is equally true that health services are as much an investment as education. Health services and education must now be regarded as twin endeavours, advancing mankind. Neither will attain its full potential for good if one is allowed to lag behind the other. Progress in one must be paralleled by progress in the other. The fruits of this progress must be available to all.

There cannot and must not be any question of conflict or of priority between the needs of better education and those of good health. The economy of Canada is strong enough to carry concurrently these two essential companion services. A study of expenditures, personal and public, in other fields will convince one of that.

It may not be inappropriate to recall when Dr. Egerton Ryerson was laying the foundations of a universal elementary tax supported school system for Ontario, his proposals were as vigorously resisted by certain vested interests as damaging to freedom and to free enterprise as are the proposals for a universal tax-supported health programme being resisted today by some who fear needlessly that their world is being endangered.

I do not wish to burden you with statistics but a few figures will be helpful.

Canada's population is now 20 million in round figures. It will increase by about 2% a year so that by 1971 the population will be 22 million and 35 million by 1991. GNP will rise to 56 billion in 1971, higher if the present rate is maintained, particularly when we realize that the estimate for 1965 is almost 51 billion.

465,767 children were born in Canada in 1963. Of these, according to statistics, regarded as reliable, about 3 % or some 14,000 were or will be found to be mentally retarded, some to a great, some to a lesser degree. There are about 8 thousand blind children in Canada and an unknown but substantial number who are deaf, and thousands of others otherwise physically disabled; those with cleft palates, with hare-lips, with missing or withered limbs, the spastics, those with cerebral palsy, muscular dystrophy or cystic fibrosis and still others. These groups were always very much in our minds as we tried to visualize what ought to be their future in a health services programme for Canada. For all of these the Charter implies a new world of well-being and usefulness. For those with cancer, those who have or may develop heart disease, for the tuberculosis patients, it implies an impetus to research which we all hope may lead to spectacular results.

It is estimated that in 1963, 100 million man-days of labour were lost to the labour force of Canada through illness with a consequent economic loss of $1,630 million or about 3.8% of GNP for that year. Now, not all of this loss could have been prevented but it is a staggering loss which ought to cause the nation to seek out ways to reduce it. The economic loss due to strike action in the labour force in 1963 was 917,140 man-days. That was less than 1% of the economic loss due to illness to the labour force in the same period. These two sets of figures are unrelated, but thought provoking nonetheless. In the same year, Canadian school children, in Grades 1 to 13, lost 4.4% of all pupil-days because of illness. I have not been able to calculate this loss in economic terms but you will appreciate that it is one of major proportions.

In 1961, Canadians spent approximately $1,724 million on health services or 4.61 % of GNP with the results I just mentioned. Those results are not because our health services in Canada are of low grade or inferior. They rank amongst the best in the world.

In the period since 1961, Canada's population has been increasing at about 400 thousand a year. To maintain the 1961 physician-population ratio means that the number of physicians in active practice in Canada must go up by about 460 each year. We are going to need 460 new active practitioners each year solely from the increase in population. So it will be recognized that the extra 460 required each year is not going to be due in any way to the proposal for a universal health service. This same reasoning applies to dentists, nurses and all other health personnel who labour in the health service field. You hear a great deal about the increase in health costs. That increase is inevitable because the annual cost of health services in Canada and particularly in the Toronto area is going to rise in absolute terms from sheer weight of numbers alone and per capita as the cost of all other goods and services also rise, with or without a national-provincial programme, but of course, the increase by 1971 would be 400 million higher if all the recommendations are implemented which would mean 5.1 % of GNP at that time as compared to 4.61 % in 1961. However, if a tax supported universal programme is put into operation, there will be a major shift from the private to the public sector of the economy relieving the individual on the one hand but requiring more revenue from taxes on the other, although the overall total remains substantially the same but the risk is distributed more equitably.

The Charter, which is the foundation on which the recommendations of the Commission rest, has many implications. The most obvious of these are, of course, in the field of health care, and are spelled out in the report. There are other implications, however, which although not so obvious, are, nevertheless, important for us all; and it is some of these which I first wish to bring to your attention.

The major concern of Canadians today is national unity; the drawing together of our fellow citizens in an agreement on national aims for which we all strive in common. The debate concerning what these aims shall be, on the surface, may seem to accentuate our disagreements and diversities, but I think this view tends to overlook the basic feature of this dialogue. Any debate involves discussion of diverging and sometimes conflicting points of view, and on a national level this is particularly true in Canada with its diverse ethnic cultures and its regional, social and economic patterns. But surely, the fact that the debate takes place means that there is a degree of unity which we tend to overlook; a level of agreement that the discussion is worthwhile and that national aims arrived at in a free and open discussion are worthwhile. Surely, too, because of the social diversity which we accept as a national characteristic, the debate will embrace a wide range of viewpoints, thereby ensuring that the final agreement is not imposed from above.

Some may wish that the national purpose as embodied in programmes of social and economic action was more easily accepted without the seemingly lengthy and unnecessary debate. Those who hold those views contrast the fate of these programmes in Canada with the course of similar programmes in the United States. They see President Kennedy's "New Frontier" and President Johnson's "Great Society" as the modern extension of American revolutionary principles. These seem to symbolize the American way of life. But Canada is not a carbon copy of the United States and those who hold these views show an ignorance of the way in which history has shaped our society. Unlike the Americans we did not make the sharp break with the past; we determined to build our nation through an evolutionary movement, accepting as part of the evolving social fabric a pattern of ethnic, regional and sectarian interests. This is surely the more difficult of the two roads to nationhood and is as much a great experiment as the road chosen by the United States.

These remarks on the nature of Canadian society are a necessary preliminary to a discussion of the implications of a Health Charter for Canadians. The Charter cannot be carried like a flag into battle, thereby arousing a high degree of emotional fervour. It had to be debated in our typically Canadian fashion, for this is the way we reach agreements from which our national aims emerge. The debate goes back to the 1920's so that today there is general agreement on the principles embodied in the Charter which now becomes one of our national aims, thereby promoting our national unity.

The Charter, then, is not only a statement of principles governing our activities in the field of health, it is a contribution to national unity, something tangible, something to work for, a common denominator embracing our different cultures and ethnic backgrounds, knowing no provincial boundaries in its humanitarian concepts, nor excluding any Canadian from its protective shield, and not requiring the melting pot of uniformity. Our search for agreement, such as that embodied in the Charter, based on cross-cutting lines of diversity, although slow and difficult, serves to protect us from the many pressures to uniformity with which our technology assails us. Modern industrial man, be he a citizen of the United States, Soviet Russia or Britain, lives out his working life in an industrial environment which patterns his working activities in a distinctive and uniform manner no matter what his nationality, and this uniformity, in turn, tends to bring with it uniformity in behaviour and attitudes. But in Canada these pressures for uniformity are offset by the opposing tendencies to diversity, which lessen the levelling effects of industrialization and the emergence of a mass society with little, if any, uniqueness. The Health Charter is an example of the development of a national consensus which embraces regional, ethnic, economic, cultural and other differences. It serves to show other industrial nations how the individual can be supported in an industrialized mass society. Canadian society allows for diversity, and in the evolution of our national aims this diversity is a central feature.

Any province, or any country for that matter, could take the principles embodied in the Charter and apply them according to their particular regional and cultural situation. That is why we have stressed in the report that the Health Services Programme need not conform to a rigid national pattern. It allows an individual province to arrange its programme according to its prevailing conditions, but the basic ends of the programme must be kept clearly in mind. As we have stated, ". . . to qualify for federal support they need to provide, in whatever manner may be chosen, universal coverage in the province regardless of age or condition, or ability to pay, upon uniform terms and conditions, and to adhere to the basic inclusive features of each of the programmes recommended."

There is another possibility here which is worth noting. It may be possible for groups of developing nations, and I am thinking particularly of the new African states, to cooperate in health programmes, by agreeing on the goals of the Charter and then applying them in the individual countries concerned. This is surely a major implication of the Health Charter. The Canadian experience in seeking to apply national, economic and social policies within a pattern of regional and provincial political, social, economic and cultural differences is surely an example which these developing nations can study to their advantage.

I would like to make another point concerning the implications of the Health Charter. Too often in the formulation of particular government policies affecting our economic and social well-being there is an emphasis on the goals of the specific policy which in so many cases are specified in economic terms. This it true even in the field of health. This emphasis on economic goals might make one believe that all our values are strained through the bars of the dollar sign. The Health Services Programme enunciated by the Commission, however, is based on a clear statement of underlying principles embodied in the Health Charter. Perhaps we can hope that this will serve as an example to those who formulate policy so that in the future they will make explicit the values which guide them. Such explicit statements of underlying values would serve to emphasize the basic consensus which binds together the diversity which is Canada.

The Charter has implications of a national and local nature as well as implications of an international nature. In the international field it implies that Canadians will give more than lip service to the principles of the World Health Organization to which as a nation it subscribed. Those principles set out in the preamble of the WHO Charter are as follows

The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition.

The health of all peoples is fundamental to the attainment of peace and security and is dependent upon the fullest co-operation of individuals and States.

On the Canadian scene it aims at health services of an ever rising quality. That quality will be achieved by greater support of medical, dental and other institutions; by greater support of research, all of which would be co-ordinated "to make available to all Canadians the best possible health care which we can now foresee, but above and beyond that it would provide foundations upon which the genius of Canada's scientists would flourish and open up vistas of better things to come as science proceeds to uncover the secrets of disease and to discover new methods in the age-old struggle to conquer it."

Co-ordination means planning at all levels of government. The haphazard approach heretofore followed has to be superseded by planned co-ordination in order to get the best results in a field where first-rate research scholars are at a premium and the money to support needed research projects never sufficient. Accordingly, in this area and at an early stage the Charter envisages:

(1) A Health Planning Council of Canada appointed by government from panels recommended by professional bodies, such as doctors, dentists and nurses and from voluntary agencies, from business, labour and farm organizations.

(2) The expansion of the existing Medical Research Council with the addition of outstanding persons from the other health professions under the name of the Health Sciences Research Council, and as so reconstituted to be the principal adviser of the Government of Canada in the planning and support of health research and the allocation of research funds, its services to be available to provincial governments, voluntary health organizations and universities.

A host of new disciplines has been added to the traditional health team: the social scientist, the social worker, the architect, the administrator, the statistician, to mention a few, all must participate in the study of health and health services.

Personally I am confident that the quality of our health services will rise and continue to rise. The dedicated men and women in the faculties of medicine, dentistry, nursing and the other disciplines will continue to reach for improvements and the responsible leaders of the professions will set standards of proficiency which will, in whatever form our National Health Service take, redound to the honour of the professions and the better health of Canadians.

The fundamental implication of the Charter is that of Freedom; services to be rendered by free, independent, self-governing professions, and those seeking health services are to be as free to choose as they have always been. The physician continues in private practice. He renders the service which, in his judgment, his diagnosis indicates. The state does not interfere in any way with his professional management of the patient's condition, nor with the confidential nature of the physician-patient relationship. Only the manner of receiving payment is altered. Moreover, any physician is free to practise independently of the programme, either wholly or partially. There will undoubtedly be some patients who, though covered, will elect to make private financial arrangements to avail themselves of the services of such physicians. In this, you will see similarity with the right of a parent to send his child to a private school and to pay the tuition fee to the private school even though he is entitled to send his child to the tax supported elementary or high school system without charge.

Another essential in this context of freedom is the opportunity for voluntary organizations to play their part, along with private practitioners, government and local bodies, in the future organization and provision of health services.

The Charter foresees the structuring of health services to bring to our Indians and Eskimos health services, within the limitations of geography and climatic conditions, of a standard equal to that being provided to other Canadians.

The Charter envisages a restructuring of the formation of nurses making the qualifying of nurses more of an educational experience and the calling a truly professional one.

Home Care programmes would be fostered to relieve hospital congestion and waiting lists.

It foresees a children's dental programme without which the dental needs of Canadians cannot be adequately met.

It would bring optometry to the campus of the university making that calling a profession within and as part of the traditional health team.

It would place an emphasis heretofore lacking on the importance of prevention in the whole health field and on rehabilitation following illness or disability.

It would make the pain-relieving and the life-saving drugs available to all at a nominal cost and free to all requiring long-term therapy.

And to achieve these implications, it sees the physician and the dentist adjusting to the new demands both in specialization and general practice and it sees an up-grading and expansion of medical general practice so that the status of the general practitioner will be assured and the personal and family physician relationship maintained.

So in a very special way the Charter holds out new hope to the aged and infirm, to the crippled, the retarded, the blind, the deaf, to those destined to develop cancer or heart disease. It holds out the hope that by a proper examination to all newborn babies, fewer will become blind; that all those with hearing defects will be recognized and treated as soon as possible; that there will be a mandatory test for P.K.U. (Phenylketonuria) and so permit a child to escape its effects and a lifetime of mental retardation; that those retarded will be given every opportunity to have as normal a life as may be possible and by providing an intellectually stimulating environment for these children during the first 2 or 3 years of life perhaps improve their I.Q. levels by as much as 30%, thus dispelling the theory held until now that I.Q. levels were unchangeable.

Then there are the mentally ill. To realize the magnitude of this problem one needs but to recall that today in Canada some 70 thousand patients are in mental or psychiatric hospitals and it is estimated that some 10% of the population or about 2 million persons may be suffering from psychiatric and emotional disorders of varying degrees. The implications of the Health Charter for these-those now in institutions and those who may need treatment-is that there will be an end to the distinction made towards those who are mentally ill and those who are physically ill; that there will be an increasing awareness of the possibilities of improved treatment; a more widespread understanding of the tremendous cost to the economy and to society resulting from the lack of contribution of the mentally ill and the length of their treatment and an end to the walled asylums in which hope died and human beings vegetated.

And lastly the Charter implies a nation awakened to the dangers of water and air pollution, to motor vehicle and other accidents; to alcoholism and to drug addiction.

May I close with a quotation from Volume II of our report. In the three and one-half years of our study, we probed the problems of Health Services in Canada more widely and in greater depth than had been done before. We believe we glimpsed the vision of what could be; of what Canada could do in the coming decades, holding to what is good in our present medical and health practices but not fearing to accept new ideas and new methods:

"We have in Canada a land of immense resources. We must use them for the good of all Canadians. We have here an opportunity to build upon the northern half of this continent a nation of educated and healthy people. Nature itself favours such a possibility. Admitting that climatic conditions in the northern areas are often forbidding, nevertheless the country as a whole is singularly free of those hazards to good health to be found in so many parts of the world. It is for us so to organize our resources in harmony with our favoured situation that Canada may become a showplace of man's humanity to man. We will rightly stand condemned by history if we fail to do what our people need and what our resources and our know-how make readily possible."

Thanks of the meeting were expressed by Mr. Alexander Stark, Q.C.